Klinische Kompetenz

Klinische Kompetenz:
Nostalgie oder
Notwendigkeit
F.Follath
Elemente der klinischen Kompetenz
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•
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Fachwissen
Arzt-Patienten Kommunikation
Untersuchung am Krankenbett
Integration und Interpretation der Befunde ⇒ Diagnose
und Therapieentscheide
• Spezielle Untersuchungen, Interventionen, Operationen
(Fachgebiete)
2
ANAMNESE
Hygieia
Asklepios
3
PALPATION
4
AUSKULTATION
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Moderne Diagnostik
Bildgebende Verfahren
- Ultraschall
- Computer-Tomographie (CT)
- Magnetresonanz
Laboruntersuchungen
- Hämatologie
- Chemie
- Immunologie
Molekularbiologie
6
EuroHeart Failure Survey
• 25 Countries
60 Clusters
116 Hospitals
• 45,933 consecutive hospital medical admissions screened
• 11,016 (24%) patients enrolled with heart failure
Epidemiology of HF
Framingham Study
7
NYHA-Klassifizierung
New York Heart Association
I
Patienten mit Herzkrankheit ohne Limitation der
physischen Aktivität bei alltäglichen Belastungen
II
Leichte Limitation der physischen Aktivität. Alltägliche
Belastungen verursachen Müdigkeit, Palpitationen,
Dyspnoe oder Angina pectoris
III
Starke Limitation der physischen Aktivität
Beschwerden bereits bei geringen Anstrengungen
IV
Beschwerden bei jeder Form der physischen Aktivität
Symptome gelegentlich auch in Ruhe
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IMPROVEMENT Study
(Swiss patients, n=472)
14,2 %
42,2 %
32,4 %
11,2 %
Muntwyler, SMW
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Jugularvenen-Stauung
10
Prognostic importance of elevated JVP
and 3rd sound in Heart Failure
Drazner, NEJM, 2001
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Palpation der linken Kammer „Spitzenstoss“
Impulse >3 cm Breite
Sensitivität: 92 %
Spezifität: 91 %
für LV-Dilatation
Eilen, Ann. Int. Med. 1983
12
Diagnose der Herzinsuffizienz:
Beitrag der klinischen und der einfachen
diagnostischen Methoden
Sensitivität
1. Klinische Untersuchung
2. EKG *
3. Thoraxröntgen (Herz ↑)
Kombinationen 1 + 3
1+2
1+2+3
Spezifität
81%
98%
71%
47%
69%
92%
92%
98%
100%
91%
76%
95%
* Normales EKG spricht gegen HI!
Ref.: Gillespie et al, Brit Med J 1997
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POSSUM physiological and operative variables
Physiological variables
Age
Cardiac history
Respiratory history
Blood pressure
Pulse rate
Glasgow coma score
Haemoglobin level
White cell count
Urea concentration
Na+ level
K+ level
Electrocardiography
Operative variables
Operative severity
Multiple procedures
Total blood loss
Peritoneal soiling
Presence of malignancy
Mode of surgery
Brit J Surg, 2004
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Predicting postoperative morbidity by
clinical assessment
Markus, Brit J Surg 2004
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Pearls and pitfalls in patient care: need to
revive traditional clinical values
Despite the incredible advances, and many more promised.
There is ample evidence that all is not well within medicine:
1. Misdiagnosis remains surprisingly common
2. A cause for concern is the toll of iatrogenic illness
3. Many patients are seeking alternative to conventional medicine
4. Healthcare costs are rising an alarming rate in all developed
countries
- ordering of unnecessary test
- demand for the newest technology even when it is out
of clinical context
Schattner & Fletcher, Am J Med Sci 2004, 327 (2):79-85
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Arzt-Patienten Kommunikation
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Mean time to interruption
of opening statement
Preference of information type
patient vs doctor
( Beckman and Frankel)
( Kindelan und Kent, 1987)
number of patients
concerns expressed before interruption
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Percentage of patients preferences
percentage of doctors preferences
40
25
20
30
15
20
10
10
5
0
0
g
olo
6,83
16,5
25
37,5
mean time to point of
interruption (seconds)
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Patienten-zentrierte Kommunikation
(Disease-illness model) nach Stewart und Roter, 1989
Patient präsentiert Problem
Information / Gespräch
Parallele Bereiche
Subjektives Krankheitsempfinden
(Illness)
Patientensicht:
• Vorstellungen, Ideen
• Ängste
• Erwartungen
• Gefühle / Gedanken
• Auswirkungen
Krankheitserfahrung des Patienten
verstehen
Krankheit / Diagnose
(disease)
Arztsicht:
• Symptome
• Befunde
• Untersuchungen
• Pathogenese
• Auswirkungen
Differentialdiagnose
Integration der Sichtweisen
Erklärungen und Planung:
geteiltes Verständnis , gemeinsame Entscheidungen
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Trends in Alternative Medicine
Use in USA 1990 - 1997
JAMA, 1998
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Popularity of alternative medicine
1. Most alternative medicine systems carefully attend to the illness
and suffering that accompanies al diseases
2. The time spent with each patient by an alternative medicine
preactitioner usually exceeds that spent by the average conventional physician
3. Patients are often more satisfied with their interactions with
unorthodox than orthodox medical practitioners
4. Alternative medicine practitioners provide patients with understanding, meaning, and self-care methods for managing
their condition
These elements are easily lost in the subspecialization, technology,
And economics of modern medicine
Editorial JAMA Nov. 11, 1998
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The Teaching and Practice of Cardiac
Auscultation during Internal Medicine and
(A Nationwide Survey)
Cardiology Training
S.Mangione et al, Ann.Int.Med.119:47,1993
• Results
27.1% of internal medicine and
37.1% of cardiology programs offered any structured teaching
of auscultation
Trainees`accuracy ranged from
0% to 56.2%
for cardiology fellows (median, 21.9%) and from
2% to 36.8%
for medical residents (median, 19.3%)
• Conclusion:
A low emphasis on cardiac auscultation appears to have
affected the proficiency of medical trainees.
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Cardiac auscultatory skills
Internal medicine and family practice
Mangione, JAMA 1997
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Mastering Cardiac Murmurs
The Power of Repetition
J.Barrett et al.Chest.2004;126:470-475
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Study objectives:
To determine wether intensive repetition of four basic cardiac murmurs
improves auscultatory proficiency in medical students
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Interventions:
(1)
monitored group,
(n=20), 500 repetitions of each murmur
(2)
unmonitored group, (n=21) 500 repetitions of each murmur
(3)
A control group
(n=10)
Results:
Improvement
1.
monitored group following intervention
13.5 + 9.8 to 85 + 17.6%
2.
unmonitored group
20.9 +10.9 to 86.1 + 15.6%
3.
Control students no improvement
24 + 21.7 to 32
+ 22.5%
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Relationship between Clinical Experience
and Quality of Health Care
N.Choudhry et al.Ann Int.Med 2005;142:260-73
• Purpose:
Systematical review of studies relating medical knowledge and health care quality
to years in practice and physician age.
• Data Sources:
English-language articles from 1966 to June 2004
• Results:
¾ 52 % decreasing performance with increasing years in practice for all
outcomes assessed;
¾ 21 % decreasing performance with increasing experience for some
outcomes but no association for others;
¾ 3 % performance initially increased, peaked and then decreased.
¾ 21 % no association
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„Practice makes perfect“...or does it?
Weinberger S.E&Duffy F.D. Ann.Int.Med 142:302,2005
Practice does not make perfect, but it must be accompanied by
ongoing active effort to maintain competence and quality of
care:
1. Professional development: a concept applicable to physicians
throughout their professional lifetime.
2. Continuing medical education should be active, self-directed,
and embedded in clinical experience
3. Physicians must know the current evidence-based standards of
care.
4. Internal medicine should be a leader in educating physicians to
improve quality of care.
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Schlussfolgerungen
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Die Arzt-Patienten Kommunikation und die sorgfältige klinische
Untersuchung spielen auch in der modernen Medizin eine
zentrale Rolle.
Rolle
•
Während des Medizinstudiums, in der Weiterbildung und in der
kontinuierlichen Fortbildung sollte die klinische Kompetenz
gezielt gefördert werden.
•
Patienten benötigen auch heute eine individualisierte,
einfühlsame Betreuung,
Betreuung Apparate und Guidelines sind kein
Ersatz.
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Der rationale und ökonomische Einsatz der modernen
Diagnostik basiert auf einer kompetenten, initialen klinischen
Beurteilung.
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RESERVE
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INSPEKTION
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Perikarderguss
Computer Tomography
Myxom
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Probleme bei der Bewertung der
klinischen Kompetenz
1. Nicht direkt messbar oder quantifizierbar
2. Sicht von Patienten, Kollegen und
Pflegenden variabel
3. Für die akademischen Karriere wenig
nützlich (Citation index & impact factors
massgebend)
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The Swiss Virtual Skills Lab - Project
• Interaktive, internet-basierte e-learning module (n=13)
der Schweiz.Med.Fakultäten (Koordination Lausanne)
• Module der Uni-Zürich
¾ History taking and doctor-patient communication
¾ General examination (Internistischer Status)
¾ Cardiovascular examination
• Team:
¾ Monika Witzig, Tamara Rodorf, Ulrike Kümmerle,
Liliane Follath
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Current Perspectives I
Bedside Science Reduces Laboratory Art
- Appropriate use of physical findings to reduce reliance
on sophisticated and expensive methods
Samuel Zoneraich, MD; David H. Spodick, MD Circulation 91:2089, 1995
Cardiac Auscultation
- A Glorious Past – but does it have a future?
M. E. Tavel Circulation 93:1250, 1996
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Current Perspectives II
Academia and Clinic
- Clinical Hypocompetence: The Interview
F. W. Platt, MD and J. C. McMath, MD; Denver Ann. Int. Med. 91:898, 1979
Commentary
- Words that harm, words that heal
S. E. Bedell et al Arch Int Med 164:1365, 2004
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„The Research Assessment Exercise is
bad for UK medicine“
Editorial Comment
(Lancet February 5, 2005)
1. The UK Higher Education Funding Council distributes funding
to universities based on the quality of research
- Research regarded as of international excellence
receives a large proportion of funding
- Research equating with levels of national excellence
receives less
2. Little attention was paid to the negative impact on medical
schools, which has altered and disordered the integrated
approach to teaching, clinical practice, and research
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AUSKULTATION
Holzstethoskop
Laënnec
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Diagnostischer Beitrag: Anamnese,
klinische Untersuchung und Labordaten
J.Hampton,Brit.Med.J.1975)
80 Patienten (Zuweisung an Poliklinik)
70
60
50
40
30
20
10
0
66
25
7
Bei 66 Pat. ist die Bei 25 Pat sichert Laborbefund
der klin Befund die entscheidend
Diagnose durch
Anamnese möglich anmnestisch
und richtig
vermutete Diagnose
7
Andere
Befunde
entscheidend
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Patient talking time at start of consultation
(Langewitz et al)
140
120
100
80
60
40
20
0
Number of patients
0 50 100 150 200 250 300
spontaneous taking time
(seconds)
40
The Teaching and Practice of Cardiac
Auscultation during Internal Medicine and
Cardiology Training
S.Mangione et al, Ann.Int.Med.119:47,1993
• Objectives:
Time and importance given to cardiac auscultation during
internal medicine and cardiology training and to evaluate the
auscultatory proficiency
• Study Design:
A nationwide survey of internal medicine and cardiology
program directors
• Participants:
498 (75.6%) of all 659 directors surveyed; 203 physicians-intraining and 49 third-year medical students.
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Computer
Tomography
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Ethnische Vielfalt
Single Nucleotide
Polymorphism (SNP)
Chromosomen
Krebsforschung
Pharmacogenomics
SNP Dichte
1 SNP/ 200 bp
„Drugs by Design“
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„The Research Assessment Exercise is
bad for UK medicine“
Editorial Comment
(Lancet February 5, 2005)
3. The cutting of clinical academic posts to recruit basic
scientists whose research is likely to favour RAE
ratings places additional burdens on staff
4. Some schools, to save money, have failed to appoint
professors when chair-holders retire or have
redistributed funding to appoint non-medical scientists
5. Clinical professors must be actively practising clinicians,
providing leadership with high level of competence
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Danksagungen
•
Klinische Lehrer:
¾ Rolf Schmid, OA Medizin, KSB
¾ W.Schweizer, Kardiologie, KSB
¾ J.Goodwin, Kardiologie, Hammersmith Hosp.London
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Ärzte-Teams Medizinische Kliniken A + B
Pflege Teams:
¾ CO II, CO III (Süd), CO IV b, Med IPS
¾ CO IV a (Station für persönliche Patienten)
¾ Oberschwester Elisabeth Gubler
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Sekretariat, Sprechstunde und Vorlesungen:
¾ Maya Scholz
¾ Rita Pitsch
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Klinikmanagerin:
¾ Margrit Hochstrasser
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Fotolabor:
¾ Silvia Märki
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Was ist zu tun um die klinische
Kompetenz aufzuwerten ?
• Vermehrte Berücksichtigung bei der StudentenAusbildung *
• Vertiefende praktische Kurse während der
Weiterbildung
• Wiederholungskurse im Fortbildungs-Curriculum
* Einsatz von modernen elektronischen Medien !
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